Provider Demographics
NPI:1841212784
Name:OTT, ROGER WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WAYNE
Last Name:OTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:600 W 103RD ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4560
Mailing Address - Country:US
Mailing Address - Phone:816-941-4128
Mailing Address - Fax:816-524-3150
Practice Address - Street 1:600 W 103RD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4560
Practice Address - Country:US
Practice Address - Phone:816-941-4128
Practice Address - Fax:816-524-3150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO005329111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12731011OtherBLUE CROSS/BLUE SHIELD
MO5214444OtherAETNA
MO000A921Medicare ID - Type Unspecified